Provider Demographics
NPI:1376359760
Name:ELGOGARI, ZANE
Entity type:Individual
Prefix:
First Name:ZANE
Middle Name:
Last Name:ELGOGARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 W 63RD ST
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:IL
Mailing Address - Zip Code:60501-1816
Mailing Address - Country:US
Mailing Address - Phone:708-458-0757
Mailing Address - Fax:708-458-3784
Practice Address - Street 1:7450 W 63RD ST
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:IL
Practice Address - Zip Code:60501-1816
Practice Address - Country:US
Practice Address - Phone:708-458-0757
Practice Address - Fax:708-458-3784
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1228476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant